Cardiovascular complications in patients with megaesophagus due to Chagas disease undergoing the Serra-Dória operation

The Serra-Dória procedure has been used in the treatment of advanced or relapsed megaesophagus due to Chagas disease. Little is known, however, about cardiovascular complications following this procedure. The purpose of this study was to settle independent predictors of cardiovascular complications following the Serra-Dória procedure in patients with megaesophagus secondary to chronic Chagas disease. A total of 76 patients who underwent the Serra-Dória operation for Chagas disease megaesophagus from 1998 to 2010 were included. A multivariate stepwise logistic regression analysis was performed to identify predictors of cardiovascular complications. Mean age was 61±10 years; 55% were male. Advanced megaesophagus (grades III/IV) were found in 65 (86%) of patients. Twenty-two (29%) patients had one comorbidity, and five (7%) three co-morbidities before operation. Two (3%) patients died following the operation. Twenty-nine (38%) patients presented cardiovascular complication following the Serra-Dória procedure; 15 (44%) were mild, 7 (21%) moderate, and 12 (35%) severe. Age>61 years was the only independent predictor of cardiovascular complication following Serra-Dória procedure. In patients with megaesophagus secondary to chronic Chagas disease, the Serra-Dória procedure is associated with a low mortality rate and a high frequency of cardiac complication.

Megaesophagus

Megaesophagus is a disorder of the esophagus characterized by diffuse dilation and decreased peristalsis. It is classified into congenital and acquired forms. Gastrointestinal, endocrine, immune-mediated, neuromuscular, paraneoplastic, and toxic disorders have been associated with acquired megaesophagus. Common clinical signs of megaesophagus are regurgitation, weight loss, coughing, and halitosis. Most cases of megaesophagus can be diagnosed using thoracic radiography; however, diagnosing the underlying cause requires a thorough history and additional diagnostics. The treatment, management, and prognosis of megaesophagus vary greatly depending on the underlying cause.

Recurrent achalasia in a child with Williams-Beuren syndrome

Williams-Beuren syndrome is a multysistem genetic disorder caused by the 1.6Mb hemizygous deletion involving the elastin gene in the region q11.23 of chromosome 7. The phenotype of Williams-Beuren syndrome is extremelly variable but the most common findings include cardiovascular disease, distinctive facies, mental retardation, a specific congitive profile, endocrine abnormalities, growth retardation and connective tissue abnormalities. Although gastrointestinal difficulties are one of the most constant and prominent finding of the syndrome, including gastro-esophageal reflux (GER), poor suckling, vomiting, constipation, prolonged colic, rectal prolapse, inguinal, umbilical and hiatal hernia, there have been no reports of achalasia in association with Williams-Beuren syndrome in the literature. We present the case of a boy with Williams-Beuren syndrome, achalasia and recurrent postoperative stenosis of the cardia. After Heller myotomy, the boy developed severe restenosis of the cardia with abundant adhesions which repeated after every treatment, five times in periods shorter than one month. Eventually, he developed GER, errosive gastritis and hiatal hernia which led to severe malnutrition and failure to thrive. Although the genetic defect causing Williams-Beuren syndrome might not be the direct cause of achalasia we suggest that the frequent development of severe restenosis of cardia due to tight adhesions could be the consequence of elastin gene haploinsufficiency and altered structure and function of elastic fibers in esophageal connective tissue. This case highlights the importance of early diagnosis of esophageal motor disorders in childhood which should be included in the differential diagnosis when a child with Williams-Beuren syndrome presents with dysphagia and/or regurgitation.

Achalasia of the oesophagus in infancy: a case report

BACKGROUND

Achalasia characteristically causes dismotility of the lower oesophageal sphincter and defective peristalsis of the body of the oesophagus, in response to the act of swallowing, as a result of ganglionic cells degeneration. The resultant oesophageal dilatation leads to food stasis and may cause oesophagitis and tracheobronchial aspiration. Achalasia is a rare occurrence in the paediatric age group and even more extremely rare in the neonate and young infant. Urgent radiologic evaluation of the underlying cause of persistent on-going vomiting in an infant is mandatory.

OBJECTIVE

To emphasize the role of upper gastrointestinal imaging in infants with persistent on-going vomiting, severe dehydration and malnutrition through case illustration of a 9-month-old infant seen in a private medical outfit in Lagos.

METHODS

Dilute barium oesophagogram, pre- and postoperatively, was performed in a 9-month-old infant and illustrative images were presented. Literature materials on achalasia of the oesophagus were reviewed and juxtaposed with findings in the illustrated case for discussion.

RESULTS

Only 3 to 4 percent of achalasia is reported to occur in the paediatric age group with average duration of 28 months from onset of symptoms to diagnosis. Persistent vomiting and failure to thrive are common. Pneumatic dilatations and surgical myotomy are recommended treatment methods.

CONCLUSION

Urgent upper gastrointestinal contrast study is appropriate in infants with suspected achalasia for successful management.

Electron microscopic studies of esophageal wall structures in patients with achalasia: casting more light on unresolved aspects of pathogenesis

BACKGROUND/AIMS

Previous investigations of esophageal tissue and serum probes failed to identify a common etiologic agent predisposing to, triggering or causing achalasia. In order to further examine the detailed pathologic processes resulting in achalasia we performed electron-microscopic studies of muscle biopsies taken from the LES high pressure zone in patients undergoing surgery--either Heller myotomy or esophageal resection.

METHODOLOGY

Smooth muscle biopsies with a 20 x 15-mm longitudinal segment of the myenteric plexus from the distal esophagus (lower border of the esophageal incision) in patients undergoing Heller myotomy for achalasia were taken. In patients with end-stage achalasia and mega-esophagus with esophageal resection, the complete esophageal body was available. For electron microscopy, ultrathin sections were contrasted with uranyl-acetate and plumbic citrate. The photographs were taken by a digitalized electron-microscope (ZEISS, Leo 905).

RESULTS

A striking finding was the large number of mast cells in the region of the smooth muscle layers as well as in the surrounding connective tissue and also in close vicinity to the nerve cells and to the nerve fibres. The smooth muscle cells in these regions were very often stained less intensively, and they showed signs of an acute degenerative process.

CONCLUSION

Our electron microscopic studies suggest that mast cells may play an important role in the secondary pathogenesis of achalasia. Esophageal retention and bacterial overgrowth with stasis esophagitis causing mucosal injury may be a mechanism of increased antigen exposure.

A case of mitral stenosis with achalasia

A 65-year-old woman with rheumatic heart disease and severe mitral stenosis developed dysphagia. As her dysphagia could not be directly attributed to an enlarged left atrium, she underwent barium swallow, which established the diagnosis of achalasia. This case report shows two unrelated diseases present in the same patient which individually can cause dysphagia.

Deficiency of ferritin heavy-chain nuclear import in triple a syndrome implies nuclear oxidative damage as the primary disease mechanism

Triple A syndrome is a rare autosomal recessive disorder characterized by ACTH-resistant adrenal failure, alacrima, achalasia, and progressive neurological manifestations. The majority of cases are associated with mutations in the AAAS gene, which encodes a novel, 60-kDa WD-repeat nuclear pore protein, alacrima-achalasia-adrenal insufficiency neurological disorder (ALADIN) of unknown function. Our aim was to elucidate the functional role of ALADIN by determining its interacting protein partners using the bacterial two-hybrid (B2-H) technique. Nonidentical cDNA fragments were identified from both a HeLa S-3 cell and human cerebellar cDNA library that encoded the full-length ferritin heavy chain protein (FTH1). This interaction was confirmed by both co-immunoprecipitation and fluorescence lifetime imaging microscopy-fluorescence resonance energy transfer studies. Immunoblotting showed that fibroblasts from triple A patients (with known AAAS mutations) lack nuclear FTH1, suggesting that the nuclear translocation of FTH1 is defective. Cells transfected with FTH1 and visualized by confocal microscopy had very little nuclear FTH1, but when cotransfected with AAAS, FTH1 is readily visible in the nuclei. Therefore, FTH1 nuclear translocation is enhanced when ALADIN is coexpressed in these cells. In addition to its well known iron storage role, FTH1 has been shown to protect the nucleus from oxidative damage. Apoptosis of neuronal cells induced by hydrogen peroxide was significantly reduced by transfection of AAAS or by FTH1 or maximally by both genes together. Taken together, this work offers a plausible mechanism for the progressive clinical features of triple A syndrome.

Do we really understand the role of the oesophagogastric junction in disease?

The role of the oesophago-gastric junction (OGJ) in gastro-oesophageal reflux disease is still not completely understood, and there is no clinically used method to assess the OGJ function in patients. Only indirect methods such as pH studies are carried out. The OGJ acts a valve controlling the flow of solids, liquids and gases between the oesophagus and the stomach. Manometry can determine if a sphincter is toned or relaxed; but, it cannot confirm that the sphincter region is actually open. Distension is a new technique for measuring function in the OGJ. By measuring the cross-sectional area through the narrow region in the junction during distension of a catheter mounted bag, much more information on the opening and closing patterns of the junction can be determined. This technique has already been demonstrated to show changes in the OGJ after surgical treatments for reflux disease. New measurement ideas around the concept of distending the OGJ offer new hope that a clinically useable test for compliance at the junction can be developed and could potentially help in determining appropriate therapy.

Pseudo-achalasic behaviour of a middle thoracic esophageal squamous cell carcinoma

Pseudo-achalasia is a rare pathologic entity that mimics idiopathic achalasia, usually secondary to malignant infiltration of the cardia. Its significance is related to the fact that it may be difficult to distinguish from primary achalasia; the outcome and therapeutic course are different. In fact, a large variety of processes may be responsible for the development of a secondary achalasia syndrome; we present a case with pseudo-achalasia due to a middle thoracic esophageal squamous cell carcinoma.

Achalasia-like findings in a case with delayed diagnosis of H-type tracheoesophageal fistula

H-type tracheoesophageal fistula (TEF) may lead to chronic respiratory disease if the diagnosis is delayed. Long-standing fistula causes esophageal distention which is named as pneumoesophagus or megaesophagus and possibly affects the motility of the esophageal body which may also be encountered as a part of tracheoesophageal anomalies. Both dysmotility and megaesophagus may mimic achalasia radiologically and the patient may be advised an unnecessary esophagocardiomyotomy. The authors report a 15-year-old adolescent with H-type TEF who has been diagnosed during investigations for chronic respiratory disease due to presumptive diagnosis of achalasia. The authors emphasize that a complete anatomical and functional evaluation of the upper gastrointestinal tract should be done before recommending operation for achalasia in patients with chronic respiratory disease. H-type TEF should be investigated to avoid unnecessary cardiomyotomy.

Esophageal achalasia of unknown etiology in infants

BACKGROUND

Achalasia cardia is an uncommon disease in children particularly in infants. We present 8 cases of achalasia who were encountered over a 12-year period. In infantile achalasia, respiratory symptoms predominate and vomiting may easily be mistaken for gastroesophageal reflux (GER). Vomiting of uncurdled milk is characteristic of achalasia.

METHODS

In this retrospective study, the data were obtained from records of the Department of Pediatric Surgery IMS, BHU Varanasi, India. The patients were diagnosed by clinical examination and barium study. Any other associated anomalies were noted in these patients. The patients underwent esophagocardiomyotomy with antireflux procedure via the abdominal route.

RESULTS

In the present series, 7 patients survived. The follow-up study after operation showed remarkable relief of symptoms with satisfactory weight gain. No post-operative death occurred in the patients. Achalasia associated with alacrimia was noted in one infant who was lost to follow up. One infant was initially diagnosed as having gastric volvulus, but exploration revealed achalasia cardia.

CONCLUSIONS

Esophageal achalasia is a rare disease in children and its origin is generally indeterminable. Achalasia cardia should be emphasized in the differential diagnosis of an infant presenting with signs and symptoms of esophageal obstruction.

Recurrent aspiration pneumonia after laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding is a popular therapeutic option for morbid obesity. Band slippage, pouch enlargement and esophageal dilatation are occasional late complications of this procedure. There are rare reports of recurrent aspiration after banding. We report a 44-year-old female suffering from dysphagia and aspiration pneumonia 2 years after adjustable banding. Her esophagus was dilated to 6 cm, and videocinematography showed a severe achalasia-like disorder. Withdrawal of fluid from the band should be immediate, and relieved the stomal obstruction in this patient. Aspiration pneumonia is a serious late complication, which is easily treated by deflation of the band.

Simultaneous surgical management of achalasia and morbid obesity

Achalasia presenting in the context of morbid obesity is rare. The case is presented of a woman with achalasia and morbid obesity who was treated with simultaneous laparoscopic esophageal myotomy and gastric bypass. The sparse literature addressing these rare patients is reviewed and management considerations discussed. Simultaneous laparoscopic esophageal myotomy and gastric bypass is safe, feasible and provides good results.

Persisting symptoms and decreased health-related quality-of-life in a cross-sectional study of treated achalasia patients

BACKGROUND

Little is known about symptom characteristics of treated achalasia patients and their effect on health-related quality-of-life (HRQoL).

AIMS

To examine clinical remission, achalasia-associated symptoms and HRQoL in treated achalasia patients.

METHODS

The Eckardt clinical symptom score, RAND-36 and a disease-specific HRQoL questionnaire were sent to 171 treated achalasia patients.

RESULTS

76.6% of the patients returned their questionnaire. 44.9% of them were not in symptomatic remission. Prevalence of frequent dysphagia (at least daily) and chest pain (at least weekly) was 46% and 38%, respectively. Achalasia patients had lower general HRQoL scores than control subjects (all RAND-36 subscales, except health change; P < or = 0.002). Patients with frequent symptoms of chest pain and dysphagia showed lower HRQoL than patients with less frequent symptoms on three RAND-36 subscales (pain, social functioning and general health perceptions; P < 0.003). Patients in clinical remission showed higher HRQoL than patients who were not, however HRQoL in the 'remission group' remained significantly impaired as compared to controls (all RAND-36 subscales except emotional role limitations and mental health; P < 0.001).

CONCLUSIONS

Many achalasia patients remain severely symptomatic after treatment and have decreased HRQoL. Frequent symptoms are associated with lower HRQoL. Patients in clinical remission show substantially improved, but not restored HRQoL.

An endoscopic view in gastric linitis. A case report

A case of an 84 year old woman addressed for dysphagia is discussed. The endoscopic and histologic examination revealed a gastric linitis with cardial invasion. Classically, there is no characteristic macroscopic description associated with gastric linitis. An endoscopic aspect considered highly suggestive for gastric linitis is presented.

Pseudoachalasia of the cardia secondary to nongastrointestinal neoplasia

A minor proportion of patients with achalasia eventually have a neoplasm and, as a consequence, pseudoachalasia is diagnosed. A neoplasm may either involve gastrointestinal junction or present a paraneoplastic effect. Over the global diagnoses of achalasia issued in 5 years of experience in our motility unit, we have found 13% (3/23 cases) of pseudoachalasia (2-4% in previous series, probably due to the fact that the population assisted was mainly composed of elderly patients). The origin of the neoplasm was bladder, prostate and metastases from epidermoid carcinoma of vocal chord. Treatment of primary neoplasm, besides classical approach (with dilatation of botulinum injection) may help in the resolution of this clinical disorder.

Achalasia

Achalasia is a rare motor disorder of the oesophagus, characterised by the absence of peristalsis and impaired swallow-induced relaxation. These motor abnormalities result in stasis of ingested food in the oesophagus, leading to clinical symptoms, such as dysphagia, regurgitation of food, retrosternal pain and weight loss. Although it is well demonstrated that loss of myenteric oesophageal neurons is the underlying problem, it still remains unclear why these neurons are preferentially attacked and destroyed by the immune system. This limited insight into pathophysiology explains the fact that treatment is limited to interventions aimed at reducing the pressure of the lower oesophageal sphincter. The most successful therapies are clearly pneumatic dilatation and Heller myotomy with short-term success rates of 70-90%, declining to 50-65% after more than 15 years. The challenge for the coming years will undoubtedly be to get more insight into the underlying disease mechanisms and to develop a treatment to restore function.

Pseudoachalasia: not only esophago-gastric cancer

Pseudoachalasia is a rare clinical entity which has clinical, radiographic and manometric features often indistinguishable from achalasia. A small primary adenocarcinoma arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes. Rarely, processes other than esophagogastric cancers may lead to the development of pseudoachalasia. We present three cases of pseudoachalasia in which the primary cause of the disease was not an esophagogastric cancer. The causes were a pancreatic carcinoma, a breast cancer and an histiocytosis X. Aspects of these three patients' diagnostic and therapeutic course are discussed in detail.

Is aperistalsis with complete lower esophageal sphincter relaxation an early stage of classic achalasia?

BACKGROUND

Aperistalsis with complete lower esophageal sphincter (LES) relaxation, characterized by the complete relaxation of the LES and aperistalsis of the esophageal body on manometry, has been considered by some authors to be an early manifestation of classic achalasia, which is defined as incomplete relaxation of the LES and aperistalsis of the esophageal body. The aim of the present study was to compare the clinical features of patients with aperistalsis with complete LES relaxation, with those of patients with classic achalasia.

METHODS

Eighteen patients with aperistalsis with complete LES relaxation and 53 patients with classic achalasia were analyzed with regard to clinical history, the maximal diameter of the esophageal body on barium esophagogram, LES resting pressure and the duration of LES relaxation on manometric recordings, and the selected treatment and its efficacy.

RESULTS

The aperistalsis with complete LES relaxation group had distinctly different features compared to those of the classic achalasia group including older age, more frequent association with non-cardiac chest pain, less frequent association with dysphagia and weight loss, lower LES resting pressures, and longer duration of LES relaxation. However, the two groups were similar in terms of maximal diameter of the esophageal body, and efficacy associated with pneumatic dilation.

CONCLUSIONS

Aperistalsis with complete LES relaxation on manometry is not necessarily an early manifestation of classic achalasia. However, this condition does not preclude a diagnosis of achalasia or a good response to achalasia therapy.